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I <br /> r <br /> WELL/PUMP PERMIT <br /> SAN JOAOUM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468.3428 <br /> NON-REFUNDABLE PERMIT sjgov.org1ehd EXPIRES <br /> /'I�YEAR FROM DATE ISSUED <br /> JOB ADDRESS ClTYIZIP �` ( m <br /> CROSS STREET IN, �l1 {� AP Ni pgRCEL$I2'E LANA USE APPLICATION 3k A <br /> OWNER NAME Will <br /> f POONE w <br /> OWNER ADDRESS CrrYISTATEIZIP <br /> CONTRACTOR _ PHONE <br /> CONTRACTOR ADDRESS CITY(STATEIZIP i1 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUSCONTRACTORI/C_ONSULTANT ADDRESS C1TY)STATFJZIP <br /> LICENSE Cr�L;/-57 C C•61 FrD-09 ❑Other NUMBER 74540 EXPIRATION DATE <br /> BILLMG PARTY: I_:OWNERONTRACTOR D SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELLSAMpum--General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE ❑DOmeSlIC/Private G:Irrigaflon)Agricultural ¢Industrial D Water Quality Monitoring D Soil Samp]inglCharectedzation <br /> Q Public Water System <br /> If different from Owner: Water System Name Ce Wtit Name or Phone Nv tuber <br /> TYPE OF WORK U New Well LI Replacement Wall U Well AlterationlModification !�Other <br /> D Monitoring Well(S) #of wells C S�oillBBoring(s) nofeonnss D Geotechntca9 0o bodnge <br /> U Out-Of-Service Well 11c.Lei-Of-Service Well Renewal D Cross-Connection Repair <br /> 7 New Pum 0 Aum Replacement um Repair 7 Raise Well Casing <br /> WELL CCNSTRUCTION <br /> Drilling Method 7 Mud Rotary ❑Air Rotary D Auger ^Cable Tool 0 Push Point 7 Other <br /> Proposed Well Depth ft Excavation In diameter D Open Bottom D Gravel PacklGrevel Size in diameter <br /> D Conductor Casing in diameter I Conductor Casing Depth fl <br /> Well Casing Diameter—in ThicknesslGaugeIASTM Schell E Steel ❑Plastic D Stainless Steel D Other <br /> Grout Seal Depth ft D Neat Cement(84 Ib bag/5-10 gal water) -+Sand Cement sack mlxl7 gat water <br /> n Bentoni(20%solids) j'I Other <br /> Grout Placement Method D Pumped a Free FaIE U Other I_I Retardant IAccelerator{name) <br /> PEDESTAr- Installed By I7 Driller D Pump Contractor 7 Other <br /> d Concrete Pedestal UDimensions:Width ft Length It Thick in Lu Christy BoxU Stave PIP, <br /> PUMP D Submersible urbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERT THAT I PR ARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 1N ACCORDANCE WITH SAN <br /> JOAQUIN CO ORDIN CE ST TE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT CTIVE T E LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS O ENSATI LA S. <br /> $ U, NOTICE REQUIRED FD SPECTIONS-PLEASE CALL(299)953-7697 <br /> SIGNED TITLE DATE <br /> lid, V <br /> E VNT <br /> D <br /> 0 13 ?01p <br /> U <br /> r �N ° ru <br /> R <br /> J DEPARTMENT US ONLY ff�� <br /> Application Accepted By Date y <br /> 431�p ZO Area q� Employee ID# Drl <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By i x. Date �ofG�ZU2t7 ❑ WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck Amount Date Permltl Invoice# Well ID# <br /> Codes Into i3y_ Remitted Service Request# <br /> 38,Z 10-50 $77 13.2 0 <br /> EHQ 49 6 6r11l2Dt9 VVELLIPUMP PERMIT <br />